'Coughing up a tonsil' - oesophageal leiomyoma

We report on a case of oesophageal leiomyoma presenting as a potential cause of sudden airway obstruction. The patient presented with a large mass in the oral cavity after an episode of forceful vomiting. The operative findings and histology of which confirmed this to be an oesophageal leiomyoma emanating from the upper oesophagus, a rare finding. The mass was excised and the patient’s subsequent post-operative recovery and follow-up has been unremarkable.

This diagnosis should be borne in mind when one is referred the odd–sounding case of a patient who appears to have ‘coughed up their tonsil’.

Malignant otitis externa with skull base osteomyelitis

Malignant otitis externa associated with skull base osteomyelitis is a condition seen classically in the elderly, diabetic patient. This disease is difficult to manage, often requiring long-term antibiotic therapy. Here we present such a case, seen in a 74- year-old lady. Initially, she was treated for a number of years in the outpatient department with intermittent ear complaints, but eventually required a hospital admission that lasted for 6 months due to a severe malignant otitis externa complicated by skull base osteomyelitis. We will discuss the clinical features, diagnostic criteria, imaging and management of this life-threatening clinical entity.

Lateral soft tissue neck X-rays: are they useful in management of upper aero-digestive tract foreign bodies?

Objectives:

To assess the value of lateral soft tissue neck X-rays in patients presenting with upper aero-digestive tract foreign bodies.

Design:

Retrospective study.

Inclusion criteria:

(1) Patients referred to the ENT team, via either the accident and emergency department or their general practitioner; (2) a history of a non-aspirated, upper airway, aero-digestive tract foreign body; and (3) a lateral soft tissue neck X-ray taken on admission.

Results:

A total of 62 patients met the inclusion criteria. Twenty-four patients (38.7 per cent) had positive findings on lateral soft tissue neck X-ray. ‘Soft’ signs, such as widened pre-vertebral shadow and loss of lordosis, were seen in all 24 patients, and foreign bodies were visualised in six patients. Overall, lateral soft tissue neck X-rays were helpful in the management of 32 patients (51.6 per cent). Rather worryingly, doctors in the accident and emergency and ENT departments missed 79.2 and 66.6 per cent of the positive findings, respectively.

Conclusions:

A lateral soft tissue neck X-ray is a helpful tool in the management of patients presenting with upper aero-digestive tract foreign bodies. Junior doctors need better radiology training.

Hearing threshold assessment post grommet insertion. Is it reliable?

We aimed to investigate whether auditory brainstem response (ABR), assessed immediately after grommet insertion, was an accurate measure of hearing threshold.

Ten children were recruited (20 ears). Patients underwent transient evoked otoacoustic emission (TEOAE) and ABR tests before and after grommet insertion under general anaesthetic. A third assessment was conducted at a six-week review, without anaesthetic or sedation. The hearing threshold in dB and the presence of TEOAE were recorded by senior audiologists. The results of each investigation were compared. At review, only 15 ABR and 17 TEOAE tests, of a possible 20, were recorded.

Transient evoked otoacoustic emissions were recorded in 30 per cent of ears pre-operatively, 20 per cent of ears post-operatively and 82 per cent of ears at six-week review. The average ABR thresholds were 23.75 dB (range 10–45 dB) pre-operatively, 27.25 (range 15–40 dB) post-operatively and 15 dB (range 5–25 dB) at six-week review. Comparing pre- and post-operative assessment, decreased thresholds were seen in six ears and elevated thresholds in 11. Comparing the six-week review ABR with the post-operative ABR, 13 ears had decreased thresholds, by as much as 20 dB. Thresholds of 35 dB or greater were measured in six ears immediately after grommet insertion (maximum 40 dB). Threshold shifts of 15 dB or greater was observed in seven ears. The intra-subject variation was shown to be significant (p<0.001) when repeated measures analysis of variance was applied.

We conclude that there is evidence that ABR can be inaccurate after grommet insertion, overestimating hearing thresholds. We believe that the mechanism by which the error is realised is temporary threshold shift.

Treatment of pinna haematoma with compression using Leonard buttons

The standard treatment of a pinna haematoma involves drainage and compression to prevent recurrence and subsequent disfigurement. Compressive methods can be non-invasive or invasive, utilising a head bandage or through and through sutures, respectively, to keep compression in place. Leonard buttons are effective alternative compressive devices. They are simple to use and easily available.

Cartilage tympanoplasty for posterosuperior retraction pockets of the pars tensa in children

OBJECTIVE

To assess the functional and anatomic results of cartilage grafting in children with a severe retraction pocket of the posterosuperior part of the pars tensa and operated on by pocket excision and cartilage grafting.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Fifty six children (60 ears) with severe posterosuperior retraction pockets.

INTERVENTION

Excision of the pocket and tympanic reinforcement with a tragal or conchal cartilaginous graft.

MAIN OUTCOME MEASURES

Postoperative anatomic (otoscopy, computed tomography) and functional (pure tone audiometry thresholds) outcome. The follow-up time was 27 +/- 18 months (mean +/- SD).

RESULTS

Retraction recurrences requiring additional surgery occurred in 5 cases (8%). The risk of recurrence was lower in children older than 10 years and when the whole surface of the pars tensa was reinforced (chi(2) test, p< 0.05 for both factors). Functionally, hearing was improved even when the ossicular chain was intact. In case of disrupted ossicular chain, direct contact between the graft and eroded incudostapedial joint gave good hearing results.

CONCLUSIONS

Cartilage reinforcement of the whole surface of the pars tensa is probably the best treatment of a severe posterosuperior retraction pocket. The flexibility and thinness of cartilage from the cymba conchae makes it particularly suitable in this indication.

The effect of prone posture on nasal temperature in children in relation to induction of staphylococcal toxins implicated in sudden infant death syndrome

The incidence of sudden infant death syndrome (SIDS) has declined in response to campaigns discouraging the prone sleeping position. Recent work suggests some SIDS death may be in response to bacterial toxins produced in the upper airway. A minimal temperature of 37 degrees C is required for induction of the pyrogenic toxins of Staphylococcus aureus identified in many SIDS infants. This aim of this study was to test the hypothesis that the prone position raises the temperature of the upper airways in children. A pilot study of 10 children (aged 3-8) and a main study of 30 children were carried out. Nasal septal temperatures were measured with an infra-red thermometer with the subjects in upright and prone positions under controlled conditions of ambient temperature and humidity. In both the pilot study and main study, nasal temperatures in the prone position were significantly higher (P < 0.01) Five subjects' prone readings were 37 degrees C or higher. These findings suggest that lying prone raises the upper airway surface temperature towards that required for toxin production. This could be one means by which the prone sleeping position contributes to the risk of SIDS.

The protective effect of breast feeding in relation to sudden infant death syndrome (SIDS): III. Detection of IgA antibodies in human milk that bind to bacterial toxins implicated in SIDS

Two toxin-producing bacteria implicated in sudden infant death syndrome (SIDS) are Staphylococcus aureus and Clostridium perfringens. Epidemiological studies have shown that breast feeding reduces an infant's risk of SIDS. This protective effect could be due partly to IgA antibodies to these toxins in human milk. The aim of this work was to use a quantitative ELISA to determine levels of IgA antibodies that bound to toxic shock syndrome toxin (TSST-1), staphylococcal enterotoxin C (SEC) and C. perfringens enterotoxin A (CEA) in individual samples of human milk. All samples of milk tested contained IgA antibodies that bound to the bacterial toxins. For individual samples, IgA bound to TSST-1, SEC and CEA were in the range of 900-3100 ng ml(-1), 1000-3600 ng ml(-1) and 1000-4300 ng ml(-1) respectively. Isolation of S. aureus from mothers donating breast milk samples was used to determine if the presence of bacteria affected IgA levels which bound TSST-1 and SEC. For 3/5 samples with levels above the upper limit of the standard deviation (2375 ng ml(-1)) for IgA bound to TSST-1, S. aureus was isolated from the mother whilst 4/5 samples found to contain levels above the upper limit of the standard deviation (2627 ng ml(-1)) for IgA bound to SEC, had S. aureus isolated from the mother. In conclusion, if bacterial toxins do play a role in precipitating a SIDS death, the presence of IgA antibodies to toxins in breast milk, but not in infant formula, might contribute to the protective effect of breast feeding in relation to SIDS.

Day case tonsillectomy in adults: how many are suitable?

Day case surgery is increasing to improve health care cost efficiency. The economic benefits of day surgery depend on how many patients are suitable. Adult tonsillectomy is a common operation. This study aims to define what proportion of adults undergoing tonsillectomy are suitable for day case surgery. One hundred consecutive adults undergoing elective in-patient tonsillectomy were studied prospectively. Patients were questioned, examined and investigated for any general medical or social contra-indications to day surgery as specified by the Royal College of Surgeons of England. They were also questioned about specific contra-indications to day case tonsillectomy, including NSAID contra-indications and tonsillectomy indicated for biopsy, quinsy or with another procedure. Seventy-six per cent patients satisfied the requirements. The most common reasons for failure were social. A high proportion of adults are suitable for day case tonsillectomy and therefore significant economic benefits are possible. However, prior to such surgery further work on operation suitability is required.